Transcript 263642

PNEUMONIA IN THE ELDERLY
1
A Primer to Clinical Documentation
WI ACDIS Chapter
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR,
FCS, PCS, CCDS, C-CDIS
PNEUMONIA

PneumoniaInfection of the aleveoli, distal airways, and
interstitium of the lungs
 Inflammatory disease of the lung characterized by
the production of a vascular response (hyperemia
and vascular permeability) and an exudate
 Caused by bacteria, viruses, fungi, and parasites
 Typically classified as “community acquired” or
“healthcare/hospital acquired”

2
PNEUMONIA
Community Acquired Pneumonia- diagnosed
outside the hospital or is diagnosed within 48
hours after admission to the hospital in a patient
who has not been hospitalized in an acute care
setting for 2 or more days within 90 days of the
infection or has not been hospitalized or residing
in a long term care facility for more than 14 days
before the onset of symptoms.
 Hospital Acquired Pneumonia/Nosocomial
Pneumonia- acquired in hospital setting.
Develops at least 48 hrs after hospital admission
 Nursing Home Acquired Pneumonia- acquired in
extended care setting.

3
HOSPITAL ACQUIRED PNEUMONIA

HAP




Carries highest morbidity and mortality rates of all
nosocomial infections
Adds 7-9 days to hospital stays
Increases costs by $2 billion annually
Crude mortality rates range from 30 to 70%
HAP defined as new or progressive infiltrate on
CXR plus at least two of the following:
Fever of > 37.8• C
 Leukocytosis with >10,000 WBCs/uL
 Production of purulent sputum


Dyspnea, hypoxemia, and pleuritic chest pain may
occur
4
IMMUNOCOMPETENT VS.
IMMUNOCOMPROMISED

Immunocompromised Patients
HIV disease
 Absolute neutrophil count < 1000/mcL
 Current or recent exposure to myelosuppressive or
immonosuppressive drugs
 Currently taking prednisone in dosage >5mg/d

5
CLINICAL PRESENTATION
Temperature > 38 •C(100.4F)
 Cough with/without sputum, hemoptysis
 Pleuritic chest pain
 Myalgia
 Gastrointestinal symptoms
 Dyspnea
 Malaise, fatigue
 Rales, rhonchi, wheezing
 Egophony, bronchial breath sounds
 Dullness to percussion
 Atypical symptoms in older patients

6
RISK FACTORS PNEUMONIA
Increased Morbidity &
Mortality







Advanced age
Alcoholism
Comorbid medical
conditions
Altered mental status
Respiratory rate >=30
breaths/minute
Hypotension (systolic
blood pressure < 90 mm
Hg or diastolic < 60 mm
Hg
Increased BUN
Overall Risk Factors




Age > 65 years
HIV or
Immunocompromised
Recent antibiotic therapy or
resistance to antibiotics
Comorbidities








Asthma
Cerebrovascular disease
COPD
CRF
CHF
Diabetes
Liver disease
Neoplastic disease
7
DIAGNOSIS OF PNEUMONIA

Radiographic studies-CXR usually adequate, can have a
auscultation-radiographic disassociation, may be negative in
early phase of pneumonia
Lobar consolidation in typical pneumonia
Bilateral, more diffuse infiltrates commonly seen in atypical
pneumonia
 “Chest X-Ray Negative” pneumonia (dehydration, CHF, pulmonary
fibrosis)



Blood cultures should precede antibiotic therapy



Positive in 6-20% of cases
Most commonly yielding S. pneumoniae (approx 60%), S. aureus or E.
Coli
Sputum stain and culture
> 25 WBC and < 10 squamous adequate specimen
Sputum cultures only adequate in only 50% patients, only 44% of
those samples contain pathogens
 Single, predominant organism on Gram’s stain suggest etiology
 Other stains indicated as appropriate (e.g., acid-fast stains for M
tuberculosis, special stains for fungi or monoclonal antibodies stains
for Pneumocystis


8
ROUTES OF INFECTION

Routes of infection
Aspiration of contaminated secretions-most common
 Inhalation of infected airborne droplets
 Bacteremia, and
 Direct extension of an acute inflammatory process
from an adjacent organ or structure

9
DEFENSE MECHANISMS

In the normal respiratory system there are a
number of important defense mechanisms that
protect the lung from infection. These include:
Reflex closure of the vocal cords
 Cough reflex
 Mucociliary clearance
 Macrophage activity

10
DEFENSE MECHANISMS

Increased risk of bacterial infections associated
with impairment of defense mechanisms, as in
any of these clinical situations:






Loss of consciousness
Immunodeficiency state
Pulmonary edema
Neutropenia
Chronic airway obstruction
Viral infection
11
CLASSIFICATION OF PNEUMONIA

Classification of pneumonia
Causative organism
 Pattern of anatomic involvement: lobar pneumonia or
bronchopneumonia

Lobar pneumonia- exudative inflammation involving whole
lobe, or large portion of lung
 90-95% cases caused by Streptococcus pneumoniae.
Sometimes caused by Kleb pneumoniae, Staphylococcus,
Streptococcus, H influenzae, or Gram negative bacteria


Bronchopneumonia

Characterized by focal areas of suppurative inflammation,
in a patchy distribution, involving one or more lobes
 Streptococcus pneumoniae is most common cause of
community-acquired bronchopneumonia
12
COMPLICATIONS OF PNEUMONIA
Abscess formation
 Spread of the infection to the pleural cavity
(empyema)
 Organization of the exudate (replacement of
exudate by fibroblasts)
 Bacteremia with spread of the infection to the
distant sites

13
CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum


Streptococcus
pneumoniae. Grampositive diplocci
H influenzae.
Pleomorphic gram
negative cocbacilli
Clinical Setting


Chronic
cardiopulmonary
disease; follows upper
respiratory tract
infection
Chronic
cardiopulmonary
disease; follows upper
respiratory tract
infection
14
CHARACTERISTICS OF SELECTED
PNEUMONIAS
Clinical Setting
Organism; Appearance
on sputum


Staphylococcus
aurerus. Plump grampositive cocci in
clumps
Klebsiella pneumoniae
Plump gram-negative
encapsulated rods
Residence in chronic
care facility, hospital
acquired, influenza
epidemics, cystic
fibrosis,
bronchiectasis,
injection drug use
 Alcohol abuse,
diabetes mellitus,
hospital acquired

15
CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum



Escherichia Coli
Gram-negative rods
Pseudomonas
aeruginosa. Gram
negative rods
Clinical Setting
Hospital acquired;
rarely community
acquired
 Hospital acquired,
cystic fibrosis; cystic
fibrosis,
bronchiectasis

Anaerobes Mixed flora

Aspiration, poor
dental hygiene
16
CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum
Mycoplasma
pneumoniae. PMNs
and monocytes; no
bacteria
 Legionella species

Clinical Setting


Young adults; summer
and fall
Summer and fall;
exposure to
contaminated
construction site, water
source, air conditioner;
community-acquired or
hospital- acquired
17
CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum

Chlamydophilia
pneumoniae Nonspecific
Clinical Setting

Clinically similar to M
pneumoniae, but
prodromal symptoms
last longer (up to two
weeks). Sore throat
with hoarseness
common. Mild
pneumonia in
teenagers and young
adults
18
CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum


Moraxella catarrhalis.
Gram-negative
diplcocci
Pneumocystis jiroveci.
Non-specific
Clinical Setting
Preexisting lung
disease; elderly;
corticosteroid or
immunosuppressive
therapy
 AIDS,
immunosuppressive or
cytotoxic drug
therapy, cancer

19
CDI TASK
Know Thy Antibiotic Coverage and
pharmacokinetics
 Pay Attention to Minimum Inhibition
Coverage values and antibiotic selection
 Query for Clinical Clarification and
Specificity when clinically appropriate
 Clinical Relevance/Context is key

20
INPATIENT ADMISSION PNEUMONIA

Hospitalization for pneumonia
Nursing home residents and older adults
 Adults with any of the following:

Respiratory rate > 28/min
 SBP <90 mmHg or 30 mm Hg below baseline
 Altered mental status
 Hypoxemia
 Unstable comorbid illness
 Multilobar pneumonia
 Pleural effusion that is > 1 cm on lateral decubitus CXR &
ahs characteristics of a complicated parapneumonic effusion
on pleural fluid analysis

21
PNEUMONIA SEVERITY INDEX
Pneumonia Severity Index- Risk model to assist
physicians in identifying patients higher risk of
complications and more likely to benefit from
hospitalization
 Clinical guideline for physician management,
supplemented by physician clinical judgment
 CDIS- cognizance of severity index when
contemplating pneumonia principal diagnosis
selection with concomitant conditions.

22
PNEUMONIA SEVERITY INDEX
Patient Characteristics Points
Demographics
 Male
Age (years)
 Female
Age (years) – 10
 Nursing home resident
+ 10
Comorbid illness
 Neoplastic disease
 Liver disease
 Congestive heart failure
 Cerebrovascular disease
 Renal disease
+ 30
+ 20
+ 10
+ 10
+10
23
PNEUMONIA SEVERITY INDEX
Physical examination findings
 Altered mental status
+ 20
 Respiratory rate >30 breaths per minute
+ 20
 Systolic blood pressure < 90 mm Hg
+ 20
 Temperature < 35°C (95°F) or >40°C (104°F) + 15
 Pulse rate >125 beats per minute
+ 10
24
PNEUMONIA SEVERITY INDEX
Laboratory and radiographic findings
Arterial pH < 7.35
+ 30
 Blood urea nitrogen >64 mg per dL
(22.85 mmol per L)
+20
 Sodium < 130 mEq per L (130 mmol per L) + 20
 Glucose >250 mg per dL (13.87 mmol per L)
+ 10
 Hematocrit < 30 percent
+ 10

25
PNEUMONIA SEVERITY INDEX
Recommended Site of
Care
Risk Class
Point Total Risk Risk
lass
No
Low I
Predictors
<=70
Low
II
71 to 90
91 to 130
Low
III
Mortality
care
Recommend Site of
.1
Outpatient
.6
Outpatient
2.8
(briefly)
Inpatient
8.2
Inpatient
29.2
Inpatient
Moderate IV
26
POSTOPERATIVE RESPIRATORY
FAILURE

National Quality Measures Clearinghouse Definition
Acute Respiratory Failure

Acute Respiratory Failure in the secondary
diagnosis field



518.81- Acute respiratory failure
518.84- Acute-on-Chronic respiratory failure
Discharges meeting the following criteria with
518.81 or 518.84 in secondary diagnosis field



Mechanical Ventilation for 96 consecutive hours or more - zero
or more days after the major operating room procedure code
Mechanical Ventilation for less than 96 consecutive hours or
undetermined - two or more days after the major operating
room procedure code
Reintubation - one or more days after the major operating room
procedure code
27
POSTOP RESPIRATORY FAILURE CODES

518.5 Pulmonary insufficiency following trauma and
surgery
New code 518.51 Acute respiratory failure following
trauma and surgery
 Respiratory failure, not otherwise specified, following
trauma and surgery
 Excludes: Acute respiratory failure in other conditions
(518.81)


New code 518.52 Other pulmonary insufficiency, not
elsewhere classified, following trauma and surgery
Adult respiratory distress syndrome
 Pulmonary insufficiency following:




surgery
trauma
Shock lung related to trauma and surgery
28
POSTOP RESPIRATORY FAILURE CODES

New code 518.53 Acute and chronic respiratory
failure following trauma and surgery

Excludes:
Acute and chronic respiratory failure in other conditions
(518.84)
 518.8 Other diseases of lung


See revisions for ICD-9 codes 518.81 and 518.82
and 518.84
29